T86.31
BillableHeart-lung transplant rejection
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is T86.31 an HCC code?
Yes. T86.31 maps to Major Organ Transplant or Replacement Status under the V24 model but is not retained in V28.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for T86.31
For T86.31 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed T86.31 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
T86.31 is the ICD-10-CM diagnosis code for heart-lung transplant rejection. The recipient's immune system attacks and damages the transplanted heart and lungs, causing them to fail. T86.31 sits in the ICD-10-CM chapter for injury, poisoning and certain other consequences of external causes (s00-t88), within the section covering complications of surgical and medical care, not elsewhere classified (t80-t88).
Under the older CMS-HCC V24 model, T86.31 maps to Major Organ Transplant or Replacement Status (HCC 186) with a community, non-dual, aged base RAF weight of 0.910. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Document the timeframe of rejection (hyperacute, acute, or chronic) if available for clinical clarity. Because T86.31 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for T86.31 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Document the timeframe of rejection (hyperacute, acute, or chronic) if available for clinical clarity
- •Rejection is a common complication; ensure it is clearly documented in the medical record before coding
Clinical Significance
Heart-lung transplant rejection represents simultaneous rejection of both organs, creating a life-threatening emergency requiring immediate aggressive intervention to prevent dual organ failure and death. The complexity of managing rejection in both cardiac and pulmonary systems simultaneously requires specialized transplant expertise and intensive monitoring.
Documentation Requirements
- ✓History of heart-lung transplant with transplant date
- ✓Evidence of rejection in heart, lungs, or both organs
- ✓Biopsy results from endomyocardial or transbronchial sampling
- ✓Clinical symptoms affecting cardiac and/or pulmonary function
- ✓Pulmonary function tests and cardiac assessment results
- ✓Anti-rejection therapy protocols administered
- ✓Response to treatment and serial monitoring results
- ✓Coordinated care between cardiac and pulmonary transplant teams